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11-sell <br /> APPLICATION <br /> For Non-Transferable, Revocable, and Suspendae�) <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio�ihereby mad.Rto carry on business in the jun Ictional area of the San aquirlLocal Health District <br /> 69usmess Na a (DBA) r �r—/i r Atldress -�-'r �� <br /> zOwner ✓.�•�(..e -"�b?�' .`�� — a_� Address �'•e <br /> -irm Partners, Addresses and Telephone Numbers <br /> �rd usiness Telephone No. :3463F 5 1 n 5" Emergency Telephone No. <br /> Contractor Licence No. 2 - 2 <br /> Applicants Name (Print) O �" P" Title Date 5 "z A -,?2--- <br /> 'lease check Applicable Category(1-7)and Fill in the Required Information �!1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July i, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> -quipment Parking Address <br /> ,e,2. ❑ PUMPER YARD <br /> For July i, June 30, 19 <br /> No.of Vehicles Stored <br /> Vo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> pest L�Cation Test Date/Time <br /> —4. SANITATION PERMIT _ <br /> Job Address/Loc tiign 2 <br /> Dwner �`� P� Address 'al25' 7- <br /> r;3 SEPTIC TANK El CESSPOOLLEACHING FIELD PAGE PIT ❑ PACKAGE PLANT - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW UrREPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site 7—�/• <br /> '"'No.of Units Equipment Storage/Cleaning-Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 IU_ <br /> Dperator Name Where Certified <br /> ...Plant Location a <br /> Plant Capacity No. Units Served ^y <br /> T. ❑ LAUNDRY For July 1, -June 30, 19 F <br /> SIZE: ❑ Less Than 1,000 Sq. Ft_ ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home owner orlic mba daeent'saignsture cerermsthefoilowbtgu"I certify that in the performance of the work for which this permit is issued;l shall rmf employ any person <br /> M such manner as in become snblect to workman's c{mmensaticn I,' ri Cafi!muit <br /> empconloy per's hiring or sub eontreefir.g gnnmrr- �.rtr:ifle: it V.• i Mowing: 'f ceRiiy shot in the performance r i the work for which this permit is issued,I shall <br /> employpersons to n orkmar.';culapsatian inns of CaiilUrula. <br /> if <br /> I hereby certify that I have-prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and re tions of the San Joa�rin Local Health District. <br /> `APPLICANT'S SIGNATURE Xsee <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNT DUE CHECKED' <br /> GATE DATE REMITTED �1 AMOUNT V� <br /> FEE L45 Ch w S <br /> LESS <br /> PRORATION V <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> to Received by Date Receipt No. Permit No. I suan0e Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Be.2009 STOCKTOK CA 95201 <br /> .� — . <br />